Lecture 8: Sedatives and Anxiolytics

Question 1

Neurochemicals involved in sleep: sleep-promoting (4)

Answer 1

1. GABA
2. adenosine
3. acetylcholine
4. melatonin

Question 2

Neurochemicals involved in sleep: Wake-promoting (6)

Answer 2

1. dopamine
2. norephinephrine
3. histamine
4. substance P
5. acetylcholine
6. orexin (hypocretin)

Question 3

Sleep disorders (6)

international classification of sleep disorders 3rd edition

Answer 3

1. insomnia
2. sleep-related breathing disorders
3. central disorders of hypersomnolence
4. circadian rhythm disorders
5. parasomnias
6. movement disorders

Question 4

DSM5 sleep disorders (8)

Answer 4

1. insomnia
2. hypersolomnence d/o
3. narcolepsy
4. breathing-related d/o
   - obstructive sleep apnea
   - central sleep apnea
   - sleep-related hypoventilation
5. circadian rhythm disorders
6. Parasomnias
   - NREM sleep arousal d/o
   - nigthmare d/o
   - REM sleep behavior disorder
7. restless-legs syndrome
8. substance/medication-induced

Question 5

Insomnia DSM5 criteria (3)

Answer 5

1. unsatisfying sleep quantity OR quality despite ample opportunity
2. one or more of
   a. difficulty initiating sleep
   b. difficulty maintaining sleep
   c. waking too early
3. at least 3 nights a week
4. persisting for at least 3 months

Question 6

Insomnia management

non-pharmacologic) (4

Answer 6

1. CBT: first line always
2. multi-component therapy
3. daily sleep diary
4. shared decision-making

Question 7

Group sessions for insomnia (6)

Answer 7

1. sleep consolidation
2. relaxation scheduled “worry time”
3. cognitive restructuring
4. circadian rhythm entertainment
5. sleep hygiene
6. stimulus control

Question 8

Insomnia management: sleep hygiene (8)

Answer 8

1. NO nicotine, alcohol, or caffeine
2. regular exercise hours before bed
3. use bed only for sleep or sex
4. regular wake/sleep times
5. avoid daytime naps
6. avoid large amounts of liquid in evening
7. comfortable environment (cool, arid, quiet, secure)
8. relaxing and enjoyable activity before bed

Question 9

Safe hypnotic prescribing (4)

Answer 9

1. lowest dose possible for effective dose for a limited duration
2. avoid prescribing a dose greater than the maximum recommended dose
3. avoid combining with CNS depressants
4. use increased caution in older adults and patients with renal and/or hepatic dysfunction

Question 10

Available hypnotics (7)

Answer 10

1. benzodiazepine
2. non-benzo BZD-Ras
3. Melatonin receptor agonist
4. Orexin receptor agonist
5. Antidepressants
6. Antihistamiens
7. OTC supplement/herb
   
   • melatonin
   • valerian

Question 11

Pt. education and monitoring (5)

Answer 11

1. patients w/ cobormid depression, asses for suicidal ideation before prescribing and if present, monitor closely while considering other treatment options
2. instruct patients on proper timing of the drug in relation to desired sleep onset
3. instruct patients on drug half-life and expected duration of effect
4. Advise against use if there is insufficient time for drug elimination between planned bedtime and rise time
5. most hypnotics can be used PRN instruct patient can skip dose if already somnolent

Question 12

Patient education & monitoring Pt. II

Answer 12

1. discuss rx of next day impatient in alertness, memory, coordination and driving
2. discuss rx of sleep-related behaviors such as sleep walking, eating, and driving
3. many rxed hyponitcs are controlled substances
4. schedule regular f/u to review efficacy, SE, non-pharmacologic options, asses ongoing need for rc
5. rebound insomnia may occur is used for extended period of time

Question 13

NOT recommended for insomnia (2)

Answer 13

1. gabapentin
2. atypical antipsychotics
   - quetiapine, olanzapine

Question 14

Highlights guidelines recommendations for treatment of insomnia (4)

Answer 14

1. CBT-1 as first-line
2. short acting BZDS or Z-drugs for up to 4 weeks
3. Ramelteon or Suvorexant
4. Doxepin 1-6 mg

Question 15

Neurobiology of Anxiety (3)

Part of brain?
Regulators (5)

Answer 15

1. amygdala of limbic sytem
   a. processing memory
   b. emotional reactions: flight/fight
2. regulated by
   a. norepinephrine (NE)
   b. serotonin (5-HT)
   c. corticotropin- releasing hormone system
   - supresion of hypothalamic-pituitary-adrenal axis
   d. y-aminobutyric acid (GABA)
   e. glutamine

Question 16

Non-pharmacologoical management of anxiety (5)

Answer 16

1. psychological therapy
   - cognitive behavioral therapy
   a. most effective but $$ and time
   b. identifies negative thoughts -> behavioral guide to change
2. Eye-movement sensitization and reprocessing (EDMR)
3. Exposure therapy
4. stress management
5. exercise

Question 17

Pharmacological management (10)

Answer 17

1. Benzo
2. SSRIs
3. SNRIs
4. TCAs
5. Buspirone
6. hyroxyzine
7. propanolol
8. pregabalin
   10 Misc

• atypical antipsychotics
• other antidepressants

Question 18

FDA approved drugs for anxiety BZDs (8)

Answer 18

1. alprazolam
2. chlordiazepoxide
3. clonazepam
4. clorazepate
5. diazepam
6. lorazepam
7. oxazepam

Question 19

Misc. anxiety agents (4)

Answer 19

1. buspirone
2. hydroxyzine
3. propranolol
4. pregabalin

Question 20

Algorithm for treating insomnia (4)

Answer 20

1. assess sleep habits and stressors
2. short term stressor? YES
   - consider 3-7 days z-drug
3. short term stress? NO
   - CBT
4. CBT-unsuccessful
   - z-drug, or CR melatonin
5. Asses after completion CBT
   - reasess and consider alternives
   - refer

Question 21

NOT recommended for insomnia (4)

why?

Answer 21

a. antihistamines
b. antidepressants
c. antipyshocitcs
d. melatonin

-due to side effects and/or limited evidence